Improving access to HIV Pre-Exposure Prophylaxis (PrEP): examining pharmacy delivery

Pre-exposure prophylaxis (PrEP) is a highly effective medication that HIV-negative people can take before and after sex to reduce their risk of getting HIV. PrEP is available for free from NHS sexual health clinics in England. However, some people may find it difficult to access PrEP because of the stigma associated with using sexual health services and this can lead to increasing health inequities.

Women born as women, heterosexual men born as men, ethnic minority communities, trans-people and young people are less likely to take PrEP. Making PrEP available through pharmacies could make accessing it easier for them.

The UK Health Security Agency (UKHSA) identified ‘high street’ pharmacies as important providers of public health services. Pharmacies are ideally placed to reach disadvantaged, marginalised and vulnerable populations. They already play an important role in public and sexual health work in the UK, for example by providing the emergency contraceptive pill and chlamydia screening and treatments.

Project aims
We wanted to understand if it is possible to use community pharmacies to improve access to PrEP. This includes identifying the barriers that may stop people from using them.

Scoping review: Our researchers searched 10 databases to review the published evidence. They identified 649 potentially relevant journal articles and after screening for eligibility, reviewed 56. Most of the eligible records were original publications about research conducted during or after the year 2020 in the US. This reflected a change in legislation at the time, allowing PrEP delivery through pharmacies in some states.

The research team mapped the barriers and facilitators of community pharmacy PrEP delivery identified in the literature to the COM-B behaviour change model. According to the COM-B model, behaviour change requires capability (skills and knowledge), opportunity (social and environmental), and motivation (importance and intentions).

Interviews: Once they had conducted the scoping review of the literature, our researchers went on to explore the barriers and facilitators of community pharmacy PrEP delivery for UK pharmacists and community members identified as being at elevated risk of acquiring HIV. They also used the COM-B model to do this.

During this part of the study, the team interviewed 17 community pharmacists and 24 community members, including Black African women, transgender people, and female street sex workers. The barriers to pharmacy-base PrEP delivery identified included:

- Capability barriers: lack of knowledge, training and skills among pharmacy staff; lack of PrEP awareness among clients and staff; unclear roles of pharmacists in delivering public health services

- Opportunity barriers: lack of staff time and capacity; lack of privacy in pharmacies; lack of pharmacy facilities to carry out screening and monitoring

- Motivation barriers: financial cost of PrEP to pharmacists and clients; belief that PrEP delivery could lead to risky behaviours and higher rates of STIs; not considering pharmacists as healthcare providers

Facilitators included:
- Capability facilitators: improving client and pharmacist awareness of PrEP; provision of PrEP specific training and education

- Opportunity facilitators: pharmacies having a PrEP appointment system; using pre-existing pharmacy pathways or services to deliver PrEP; accessible location and opening hours of community pharmacies

- Motivation facilitators: having an interest in PrEP; preference for pharmacy-based delivery; believing that pharmacy delivery would be more discrete and less stigmatising

Community pharmacy pilot: Our researchers then developed a pharmacy PrEP awareness raising and referral pathway intervention which was piloted in five pharmacies in the Bristol, North Somerset, South Gloucestershire region from October 2024 to April 2025. The pilot aimed to address persistent inequalities in PrEP access and uptake by integrating PrEP discussions into routine pharmacy visits. Key findings from the pilot include:

- Diverse reach: Of the 55 individuals who received a consultation, over half were female and a significant portion were people who inject drugs

- Training impact: Pharmacy staff knowledge scores nearly doubled following online and in-person HIV and PrEP training, rising from 4.77 to 9.10 out of 10

- Effective referrals: 28 community members expressed interest in PrEP, resulting in 22 referrals to local sexual health clinics for remote prescribing

- Anonymity and ease: Community members praised pharmacies for their accessibility and “anonymity,” noting they felt less intimidating than sexual health clinics

Despite the positive feedback, the study highlighted several structural challenges that must be addressed for successful scale-up:
- Clinician confidence: Pharmacists initially felt “embarrassment or unease” regarding how to raise the topic of PrEP, though confidence grew with training and experience
- Pathways and kits: Only 32% of self-sampling kits provided were returned, suggesting a need for better in-person support for complex blood tests
- Policy restrictions: Current NHS policy prevents pharmacies from stocking NHS-procured PrEP, necessitating a complex referral-to-clinic model

The research team concludes that for pharmacies to become autonomous providers, policy changes are required to allow them to stock, supply and manage PrEP prescriptions directly. This would streamline the process and potentially include the new long-acting injectable PrEP formulations.